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#1 of 28 Old 01-11-2007, 08:06 PM - Thread Starter
 
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I would like to learn more about nonreassuring fetal heart tones and pregnancy.

What if a very pregnant woman (36 wks or more) goes to her care provider for a routine prenatal appointment, and the fetal heart tones are not reassuring?

What should be done?

Why are the heart tones nonreassuring?

Is it possible that nonreassuring fetal heart tones happen to fetuses all the time, but no one knows about it?--and the fetus, the cord, and mom move around, and there is no evidence of anything?

Thanks.
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#2 of 28 Old 01-12-2007, 06:46 PM - Thread Starter
 
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anybody?

(bump)
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#3 of 28 Old 01-12-2007, 09:19 PM
 
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Can you elaborate on what kind of non-reassuring tones? Tachycardic? Bradycardic?

Amy: Certified Professional Midwife and mom to Max (11) and Stella (6).
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#4 of 28 Old 01-13-2007, 02:18 AM - Thread Starter
 
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thank you--

I am wondering about both.

I am wondering about women who go in for a prenatal and their OB says, 'Oh my, I don't like those fetal heart tones' and then the woman goes straight to the hospital and has her labor induced with Pitocin.

I am wondering about meconium staining in the fluid, as a result of bradychardia, maybe while 36 or 37 weeks old.....and if that baby is born at 41 weeks, is there any evidence of meconium staining at all?

What causes tachychardia? bradychardia? what role does maternal position play in all of this? what about the fetus? what about the fetus on the cord?

oh well..............I guess I have a lot of questions about this, and I've always hesitated to post about it online, because my questions might not be well-formed, and perhaps this is the type of thing one learns as an apprentice midwife, hands-on....but I was hoping for a midwifery/doula/this forum perspective (I've got OB textbooks and the like, and I can see what they say, but I wanna know what ya'll say.)
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#5 of 28 Old 01-13-2007, 04:48 AM
 
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You might want to get/check Michelle Murray's Antepartal and Intrapartal Fetal Monitoring. She's a PhD prepared nurse who's the "expert" on fetal monitoring. She's pretty medical, but she goes into great detail as to fetal cardiac physiology and what exactly those different heart rates represent.

As to "our" perspective-well, we don't do a lot of monitoring! Our clients are generally healthy, and a healthy fetus can handle transient, brief slowdowns in its heart rate. As to what various abnormalities mean-it depends on the reason. Fetal tachycardia from maternal caffeine intake, maternal flu with a fever, or from an infection of the amniotic fluid mean VERY different things. The latter two of these examples will have much more information than just a fast heart rate.

Hope this helps!

Jennifer
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#6 of 28 Old 01-13-2007, 11:29 AM - Thread Starter
 
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thank you for your response, Jennifer.

Maybe a question I have is, why would a homebirth care provider suggest transfer to a hospital because of nonreassuring fetal heart tones?

What would the hospital then offer?
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#7 of 28 Old 01-13-2007, 12:00 PM
 
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If the heart tones are really worrisome - the hospital offers surgery. I would have to consult if the heart tones were non-reassuring despite my best measures to improve them, and without a baby imminent. I consult to bring the OB into the picture and to meet the woman in case she needs an assisted or surgical birth.

But there are heart tones you don't *like* and actively try to help improve, and then there are the ones that dictate immediate action. How I would respond and whether I would transport in to a hospital depends on the whole picture. Sometimes it is better to stay where you are and just have a baby.

The hospital also offers more intense monitoring. I have seen it go both ways: heart tones that sounded non-reassuring at home turned out to be fine when we could plot them on the efm, and heart tones that were non-reassur at home go on to look even worse at the hospital and the baby was in trouble. This is a rare reason for transport, IMHO. Usually it is pretty obvious what is happening and whether it is safe to stay at home or safer to go to the hospital.

The problem is that using efm increases surigcal rates without improving outcomes most of the time. It takes a saavy care provider to know how to use the machines as the tool they are, and only when necessary.
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#8 of 28 Old 01-13-2007, 12:07 PM - Thread Starter
 
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Originally Posted by CarolynnMarilynn View Post
If the heart tones are really worrisome - the hospital offers surgery. I would have to consult if the heart tones were non-reassuring despite my best measures to improve them, and without a baby imminent.
What would be nonreassuring? Heart tones that stay slow, or heart tones that stay rapid? or both?

What are examples of best measures to improve them?

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Originally Posted by CarolynnMarilynn View Post
But there are heart tones you don't *like* and actively try to help improve, and then there are the ones that dictate immediate action. How I would respond and whether I would transport in to a hospital depends on the whole picture. Sometimes it is better to stay where you are and just have a baby.
Can you offer an example of a scenario where you didn't *like* the tones & try to improve them, and ones where you know it's time for a cesarean?

Is there an attitude in obstetrics that suggests a c-section is the best course for nonreassuring fetal heart tones, and is that in contrast with a midwifery attitude that would suggest maternal repositioning? Is it possible that a mom might simply need to get out of a hospital bed and stand up, instead of being wheeled into the OR suite?
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#9 of 28 Old 01-13-2007, 12:55 PM
 
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I can tell you about what I use fetal heart tones for. I may me more medically minded, but perhaps some other midwives will be along to describe their practices, too.
At a regular appt, I generally just listen with a doppler for a minute or so. I consider reassuring hearttones in that setting to be simply a rate between 120 and the 160s (or even a little higher in the first or second trimester.) I have rarely heard something concerning, and then sought further testing. Some examples of something concerning heard just on doppler in a regular appt setting would be tachycardia (rate over 170) that doesn't come down with listening for a while (frequently, I hear a baby who is moving around, or bothered by me poking at him/her whose rate will go up for a minute or so, and as I listen it comes back down -I don't worry a bit about that.) Bradycardia (rate under 120, especially under 110) would be another example, especially if it doesn't come right back up. Occasionally, I hear a brief drop in heart rate, usually associated with the baby changing position, and I don't worry about that, either. A final example of non-reassuring heart tones heard in an appt setting would be an arrythmia. Most fetal arrythmias are in fact harmless and resolve after birth, but some can be a sign of a serious problem, so usually I would seek further testing for that, too.
For all of these situations, the first further testing I would be looking for would be a non-stress test. Getting a continuous recording of the heart rate is more accurate than listening for a minute or so, so if the non-stress test is reassuring (normal baseline rate, no heart rate decelerations, and 2 accelerations within 10 minutes) I would be reassured. For tachycardia and bradycardia, if the non-stress test was good, I would look no further and probably take no action - unless there were other reasons to consider an induction, in which case the slight concern over heart tones might tip the scales in that direction. For an arrythmia, I would likely proceed to ultrasound to make sure the baby's heart appears normal and there are no signs of other illness - and possibly to fetal echocardiogram if there is reason to believe there may be anything wrong with the heart.

In labor, I often monitor intermittently (and that is my standard order.) We use either the doppler to monitor intermittent, or if the mom is near the monitor, we use the fetal monitor to listen briefly. There, I am looking for heart tones before, during, and after a contraction, and looking for a normal rate (120-160s) with no significant deceleration. Accelerations, if they are heard, are reassuring - but if not, in labor I'm not terribly worried about accels, unless there are other signs the baby isn't doing well. A significant deceleration is usually at least 10 beats per minute lasting 10 seconds or more. On a fetal monitor strip you can see more subtle decels, but they are not as concerning. If I heard a decelerations, I would first listen longer - through the next 2 or so contractions, and if all is normal, I would usually return to intermittent monitoring. If I'm still concerned, I'd switch to the continuous monitor, at least for a while. On continuous monitoring, I'm concerned if I see late decelerations (decels that start after the peak of a contraction) because they are most predictive of baby not getting enough oxygen - or if I see repetitive variable decels (decels that occur with variable relationship to contractions) that are prolonged and take a long time to recover. I don't worry at all about early decelerations, which mirror the contractions, starting before the peak of a contraction and resolving as the contraction ends. Those are caused by fetal descent and head compression and are a good sign that the baby is moving down. For concerning heart tones, my first line of action would be to make sure the mom is not on her back, trying several positions, make sure mom is hydrated, make sure mom is not hypotensive (especially with an epidural mom) and make sure we aren't causing too many contractions for the baby to recover from (as in when giving pitocin) For persistent tachycardia, I also look for hypotension (seen more often in my practice with epidurals) and fever. If fever can be reduced and BP corrected, tachycardia often resolves. I sometimes see tachycardia in the end of second stage, too - I'm guessing from the baby's stress hormones, and usually we just wait that out.
If none of that works, then you have to decide how much is too much, how low is too low, and basically guess when you think the baby might be getting to a point where it is distressed and doesn't have enough reserve to recover easily following birth. A few other markers can help you know the baby is still okay. One is fetal scalp pH, which isn't available many places. Another is to stimulate the baby by rubbing it's head, and if there is a resulting acceleration, that is as reassuring as normal scalp pH. Other than that, you have to take into account how far along the mom is, how severe the decelerations are, and how soon the baby is likely to be born - all of which, are of course, estimates. I'd be less likely to act on decels seen with a 5th time mom at 9 cms, than a first time mom at 4 cms.

Is any of that helpful?
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#10 of 28 Old 01-13-2007, 12:59 PM
 
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Is there an attitude in obstetrics that the best way to respond to non-reassuring fetal heart tones is to operate? Well, yeah. But individual docs are going to vary a lot on their threshhold for action.

Most midwives, I hope, would be first trying the things I suggested to help heart tones - reposition, hydrate, etc. I've seen examples where the heart tones were awful in one position and fine in another and vaginal birth proceeded normally as long as we kept the mom off her back. I've also seen the rare time when fetal heart tones do not respond to any supportive measure and the baby is really in distress - it's just that this is fairly rare, at least in my practice.
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#11 of 28 Old 01-13-2007, 01:15 PM
 
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ahahaaaaa.... tinyshoes, i had been following your thread and i was starting to feel a bit sorry for you, since you were obviously so very interested and you had your questions all ready and then (for a little bit)

*crickets*
*crickets*

now check it out, huh?

doctorjen just hooked you up, girl!

-anj119
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#12 of 28 Old 01-13-2007, 01:30 PM - Thread Starter
 
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anj119--I totally got my hookup!!

thank you very much drjen....your informative and comprehensive post is an excellent foundation.

Why would a fetus be in distress in the womb? I am not understanding how a near-term infant could be at risk in the womb that grew it? I do understand how in a labor scenario with Pitocin that contractions could be too forceful and would result in distress.

I am interested in this topic both for my professional development and for a personal understanding of those minimally-detailed birth stories I hear from friends and cousins, who experince the "c-section because of fetal distress." I am especially confused by my cousin whose baby showed "fetal distress" at a regular prenatal check-up after 37 wks and mom was not contracting or in labor.

That mom was sent to the hospital, induced with Pitocin, and baby became more distressed and a csection was performed. How does Pitocin help a fetus in distress?
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#13 of 28 Old 01-13-2007, 01:54 PM
 
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True fetal distress prior to labor would be rare. Some rare examples I've seen: a mom with true intrauterine growth restriction, who was also a big smoker. She had decels audible on doppler in the office at 38 weeks. On ultrasound, baby was very small, very little fluid seen, placenta very calcified. We tried induction (not to improvie the distress, but to get the baby out) Baby tolerated it not at all - first several contractions caused huge heart rate crashes (to the 50s) and a cesarean was performed. Baby was 4 lbs and 2 oz at 38+ weeks, and needed an extra week of nursery care to be able to maintain his temp and grow. The placenta was the most calcified I'd ever seen, and the baby had passed meconium (often not a sign of anything in a postdates baby, but a sign of distress sometimes prior to term.)

Another example I've seen would be a case of intervening when nothing should have been done. Baby had an obvious arrhythmia in the office. An ultrasound showed normal baby, but excess fluid. Non stress test couldn't be interpreted because the monitor couldn't adequately trace the heart rate due to the arrythmia. Consulted OB, who was worried that we wouldn't be able to adequately evaluate the fetus during labor. Cesarean performed - baby perfectly fine, arrhythmia resolved, apparently unnecesarry intervention.

Another example: Baby's heartrate over 200 in the office. Sent to hospital for non-stress test, and heartrate remains over 200. Ultrasound show heartrate over 200, fluid around the heart, fluid around the lungs, abdomen full of fluid, all consistent with fetal heart congestive heart failure. Emergency cesarean performed, baby in obvious heart failure, sent to NICU, and needed multiple heart meds, but was finally stabilized. Weird thing about this one - no cause ever found. The guess was a viral infection causing myocarditis in the baby.

As I mentioned above, pitocin would not be used to improve the heart rate, but to get the baby out because you believe the baby is potentially in danger. Unfortunately, I've seen OBs use this "the heart tones don't sound quite right" business when they just wanted an excuse to do an induction. What loving mother doesn't fret if a trusted doctor says "you're baby might be in danger" ?
Also, the typical cesarean for fetal distress scenario goes something like this: mom is induced for some reason (maybe even just oh-my-gosh-you-passed-your-due-date); because of the induction, continuous monitoring is insisted upon (and may actually be valid); nurses don't know how to help mom assume different positions and are cranky if they don't catch every heartbeat on the darn monitor; mom can't tolerate the pain of induced labor lying in bed, hungry, unable to get up to pee, afraid, with a scared husband who doesn't know what to do; an epidural is administered; the mom's BP fluctuates a lot with the epidural, plus, the baby is not positioned well because her water was broken too early and the epidural cause pelvic relaxation and caused the baby to stay posterior or asynclitic; contractions don't seem to be effective, so more pitocin is needed; baby starts to have heart rate decels from the unnatural contractions and the prolonged contractions; it is now too late to undo all the other stuff - the epidural, the broken waters, the poor position of the baby; a cesarean is done because of the "fetal distress." By the time one got to the cesarean, it may truly have been needed and the only option, it's just the whole thing leading up to it caused the bad situation to begin with.

I'm lucky that I rarely see this cascade in my own practice - because I avoid doing stupid inductions. The above examples are actually from my practice, and would give you an idea of what odd things can actually happen - but of course they are rare while the cascade of interventions thing is so much more common in US obstetrics.
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#14 of 28 Old 01-13-2007, 02:01 PM
 
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Got to run to the hospital. Will look back for any more questions!
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#15 of 28 Old 01-13-2007, 05:31 PM
 
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The example I use when I'm doing a non-stress test (usually for post dates) is to think of the last time you had the flu - how you laid in bed, motionless, zonked out? Babies can do the same thing when they are sick, conserving all their energy for growing, with nothing left over. A nice, reactive strip with good variability shows that the baby has resources to spare.

I've seen a "weird" fetal heart rate in a prenatal twice. Once it was a rate of 105 - with a reactive, but low rate on the NST done that day. The midwife faxed it to a doc who said "some babies just have periods of low rate, with that variability, it's good, just watch it" and it ended up being no problem. The other was a baby that had a "strange" rhythm - not quite even, very occasionally. He ended up having the same intermittant hiccup at his newborn exam (soooo much easier to listen to with a stethoscope than a doppler!) and got checked out by a ped the next day (since he was pink and eating well). It was considered a variation of normal, and disappeared sometime between 8 and 48 hours.

In labor, sometimes the blood flow to the baby is compromised by a uterus that contracts too much or a cord that gets compressed, or the pelvic floor relaxation that sometimes comes from an epidural.

If a baby is term, but showing signs of not being as well as it was last week, or the week before, inducing is an option. The baby's ability to tolerate labor is only going to get worse as the weeks of poor growth and inadequate resources stack up.

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#16 of 28 Old 01-13-2007, 05:46 PM
 
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sometimes, too, it helps if mom eats/drinks something prior to the exam. helps to wake baby up.

for me, if there is a funky pattern or baby isn't responsive to movement, then I start wondering. I think that many babies are sleepy and this gives poor readings for providers - same thing with having women on their back...I've seen huge dips in heart rate because of position.
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#17 of 28 Old 01-13-2007, 06:02 PM
 
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Jen, those posts were awesome! Thank you sooo much, that was really easy to digest, you would be a great preceptor, lol.

Amy: Certified Professional Midwife and mom to Max (11) and Stella (6).
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#18 of 28 Old 01-13-2007, 06:03 PM
 
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I love Jen!
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#19 of 28 Old 01-13-2007, 06:21 PM
 
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doctorjen, if I haven't said so, I just LOVE you!

tinyshoes, I could give dissertation length answers to your questions. Or, the same answer to most-"it depends".

One postdates, meconium labor might stay at home with funky heart tones and another might go to the hospital. How funky for how long? How long till a baby? What resources do I have with me, what resources are at the hospital, and what do I HONESTLY think this mom (or baby) needs?

Many posts ago, you asked what a hospital would offer, and one answer was surgery. I would also venture-a NICU and/or NICU team. I'm confident in my ability to resuscitate a baby at home, but if I see enough red flags, I might want more resources than me and my stuff (oxygen, suction). I usually have an assistant who also knows resuscitation, but not all of them do.

Great thread!

:
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#20 of 28 Old 01-13-2007, 07:14 PM
 
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Non-reassuring heart tones are a problem legally, because while the baby is almost certainly fine, if s/he isn't, there is absolutely no legal justification for not intervening. It's not the medico- part of medicolegal that does the talking in pregnancy/birth care.

My second section was an excellent example. I was 39 and 5 and planning a VBAC. I had multiple conditions making me high-risk (CHTN with a history of superimposed preeclampsia/HELLP, insulin-dependent GDM and Kell isoimmunization) and was having NSTs twice a week at that point. I went in thinking I had ruptured, had lates on the NST and had a positive CST (nipple stim, not pit). I came back the next day for another NST, which was minimally reactive. When I saw my OB for my prenatal that evening, he encouraged a repeat CS the next day. Given my risk factors and the non-reassuring testing, I knew that while the baby was probably fine, I could not rule out the possibility that she wasn't, and I was not personally comfortable with risking that possibility. When I was sectioned the next morning, she cried before her body was born and had Apgars of 8/9.

Clearly, this wasn't a case of fetal distress. But with nonreassuring fetal tracing, there was no way to know that (consistent lates with slow recovery is bad). Fetal monitoring has a place, but we really need to know more about what the monitoring means. It's too nonspecific.

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#21 of 28 Old 01-14-2007, 01:06 AM
 
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The unfortunate fact is, NO test is foolproof. If an NST is not reassuring, the next step is a CST and/or a biophysical profile (ultrasound looking at specific thing-fetal movement, fetal breathing, fetal tone, amount of fluid).

I'll never forget one woman from my hospital nursing days-her water was broken at 35 weeks. She had enough contractions to have a positive CST. Three contractions in ten minutes, the baseline was tachycardic at 160-170, minimal variablity, and deep variable decelerations down to 60 with each contraction. She got a biophysical profile, which was 8/10-two points off for the CST. Passed with flying colors.

Incredibly, she was sent to the high risk antepartum unit with orders for once a shift NSTs. (Her contractions spaced out.) She spent three days going up to high risk and coming back down with the first NST because she kept having those deep variables. Finally she got sectioned at about 36 weeks, and the baby's apgars were 9 and 9.

For some reason, this deeply offended my sense of order in the universe. What business did this baby have being just fine when everything about her monitoring was not reassuring? My nurse mentor taught me something valuable that day-simply, "we don't know sh*t."

I suppose in one way this was affirming of technology-non reassuring NST, positive CST, good BPP=baby is fine. But at that time I learned that the heart rate and monitoring is only one component of assessment.

And that's what makes us different from mainstream OB. Mainstream OB elevated the fetal monitor (the machine that goes ping) to being an oracle to the detriment of all other kinds of assessment. We never fell in love with monitors in the first place. We kept the relative importance of the baby's heart rate it in its place and didn't forget to assess the mom, the circumstances, and our hunches.

Keep up your inquisitiveness, tinyshoes!

Jennifer
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#22 of 28 Old 01-14-2007, 02:03 AM
 
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My nurse mentor taught me something valuable that day-simply, "we don't know sh*t."
And that's exactly what my OB said when he was sewing up my belly. But legally, to not intervene given a positive CST and multiple risk factors would have been indefensible, and it still pisses me off that is reality for birth providers.

mama to Max (2/02) and Sophie (10/06); wife to my fabulous girl
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#23 of 28 Old 01-15-2007, 03:19 AM
 
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There are lists of things get yourself a few OB texts and read up on it--

things that can cause a baby to not be well- Rh factor sensitization
infection- and this one is probably bigger than we think-
primary disease states in mom or diseases of pregnancy like
High blood pressure - renal disease, liver disease, diabetes, meds genetic/metabolic disorders , autoimmune, clotting factor problems
trauma,Pre eclampsia, elcampsia, twin to twin transfusion,

genetic disorder of a baby, true knot in a cord- placental abruption...

unknown

how well is a baby responding to stimuli?
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#24 of 28 Old 01-15-2007, 11:55 AM - Thread Starter
 
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Quote:
Originally Posted by doctorjen
True fetal distress prior to labor would be rare. Some rare examples I've seen: a mom with true intrauterine growth restriction, who was also a big smoker. She had decels audible on doppler in the office at 38 weeks. On ultrasound, baby was very small, very little fluid seen, placenta very calcified. We tried induction (not to improvie the distress, but to get the baby out) Baby tolerated it not at all - first several contractions caused huge heart rate crashes (to the 50s) and a cesarean was performed. Baby was 4 lbs and 2 oz at 38+ weeks, and needed an extra week of nursery care to be able to maintain his temp and grow. The placenta was the most calcified I'd ever seen, and the baby had passed meconium (often not a sign of anything in a postdates baby, but a sign of distress sometimes prior to term.)
Great example; that makes sense.

Quote:
Originally Posted by doctorjen
Unfortunately, I've seen OBs use this "the heart tones don't sound quite right" business when they just wanted an excuse to do an induction.
How can they do that?

I can understand many of the things OBs think or say, like, episiotomy is better than a tear--but this 'heart tones' stuff looks like a complete lie...what justifications could a highly medically-minded care provider have in mind when telling this to a pregnant woman?

Quote:
Originally Posted by doctorjen
Also, the typical cesarean for fetal distress scenario goes something like this: mom is induced for some reason (maybe even just oh-my-gosh-you-passed-your-due-date); because of the induction, continuous monitoring is insisted upon (and may actually be valid); nurses don't know how to help mom assume different positions and are cranky if they don't catch every heartbeat on the darn monitor; mom can't tolerate the pain of induced labor lying in bed, hungry, unable to get up to pee, afraid, with a scared husband who doesn't know what to do; an epidural is administered; the mom's BP fluctuates a lot with the epidural, plus, the baby is not positioned well because her water was broken too early and the epidural cause pelvic relaxation and caused the baby to stay posterior or asynclitic; contractions don't seem to be effective, so more pitocin is needed; baby starts to have heart rate decels from the unnatural contractions and the prolonged contractions; it is now too late to undo all the other stuff - the epidural, the broken waters, the poor position of the baby; a cesarean is done because of the "fetal distress." By the time one got to the cesarean, it may truly have been needed and the only option, it's just the whole thing leading up to it caused the bad situation to begin with.
Well said.....that is the "fetal distress" I am most familiar with, and understand--and hate. It is not safe to subject babies to this dangerous scenario.
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#25 of 28 Old 01-15-2007, 11:59 AM - Thread Starter
 
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Originally Posted by Apricot View Post
The example I use when I'm doing a non-stress test (usually for post dates) is to think of the last time you had the flu - how you laid in bed, motionless, zonked out? Babies can do the same thing when they are sick, conserving all their energy for growing, with nothing left over. A nice, reactive strip with good variability shows that the baby has resources to spare.
Interesting--makes sense.

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Originally Posted by Apricot
In labor, sometimes the blood flow to the baby is compromised by a uterus that contracts too much or a cord that gets compressed, or the pelvic floor relaxation that sometimes comes from an epidural.
DrJen mentioned this too, about the lax pelvic floor contributing to fetal heart tone wierdness...bradychardic-type dips, then, would be evident? Could a position change ease this pelvic-floor issue?

Is it possible a lax pelvic floor (not from an epidural but from a sedintary lifestyle) could create a similar situation to epidural-caused relaxation?
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#26 of 28 Old 01-15-2007, 03:18 PM
 
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I don't think a sedentary life style could cause that. It's my understanding that the pelvic floor relaxation from epidural can be so great that it actually can relax the vessels to the point where the blood pressure drops. That's why the anesthesiologists are pleased when the mother has gotten 1-2 liters of IV fluids before the epidural is placed - to help prop up her blood pressure. If her BP drops from 120/65 to 95/55 after the epidural, and the baby's heart does something new, it's an easy correlation to make.

Or, the baby can "sit" on the major vessels behind the womb, because the musculature is not holding the baby "up" and away and the mother doesn't feel that funny feeling that tells her to move (you know, the one that wakes you up when you sleep funny). That's easily fixed by getting a pillow under one hip, usually.

When ever there is a heart rate that I don't like, first I check the source (ie, move the monitor...is it accurate?), then I move the mom. In the hospital, the nurse is right there (runs back to the room if absent) and we do it together (in the hospital, I go as a support person). I don't see doctors rushing to give c-sections the first time there's a serious drop or two. I see them changing positions, reducing the epidural, placing a scalp electrode so the heart rate is accurately measured, dumping in more fluids, stopping the pitocin, even giving terbutaline (to stop contractions totally), giving the baby a rest and letting labor begin again.

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#27 of 28 Old 01-15-2007, 04:49 PM
 
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Originally Posted by Apricot View Post
I don't think a sedentary life style could cause that. It's my understanding that the pelvic floor relaxation from epidural can be so great that it actually can relax the vessels to the point where the blood pressure drops. That's why the anesthesiologists are pleased when the mother has gotten 1-2 liters of IV fluids before the epidural is placed - to help prop up her blood pressure. If her BP drops from 120/65 to 95/55 after the epidural, and the baby's heart does something new, it's an easy correlation to make.

Or, the baby can "sit" on the major vessels behind the womb, because the musculature is not holding the baby "up" and away and the mother doesn't feel that funny feeling that tells her to move (you know, the one that wakes you up when you sleep funny). That's easily fixed by getting a pillow under one hip, usually.

When ever there is a heart rate that I don't like, first I check the source (ie, move the monitor...is it accurate?), then I move the mom. In the hospital, the nurse is right there (runs back to the room if absent) and we do it together (in the hospital, I go as a support person). I don't see doctors rushing to give c-sections the first time there's a serious drop or two. I see them changing positions, reducing the epidural, placing a scalp electrode so the heart rate is accurately measured, dumping in more fluids, stopping the pitocin, even giving terbutaline (to stop contractions totally), giving the baby a rest and letting labor begin again.
There's a lot of debate about how much a fluid preload to give before an epidural. The anesthesiology research mostly supports a 500 mL bolus just before placement, but a lot of anesthesia types do like more despite the lack of research. The problem is that if you then do the things it's standard to do to correct a crappy strip (change position, fluid bolus, O2, change position again), you run the risk of fluid-overloading mom and possibly creating iatrogenic pulmonary edema or even congestive heart failure.

The change in BP post-epidural isn't specific to pelvic floor relaxation; it's because the lower body's vasculature no longer responds to sympathetic pathways and so vasodilates. I've seen babies get in awkward positions from the relaxation, though, and sometimes then they get on their cords in an odd way.

mama to Max (2/02) and Sophie (10/06); wife to my fabulous girl
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#28 of 28 Old 01-15-2007, 05:13 PM
 
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Thank you maxmama - I wasn't sure I had that right! I think I have unusual experiences with epidurals because I see them in transfers, where the mama is usually dehydrated (I'd be giving fluids if we weren't transferring) and at much less risk of fluid overload, although I've seen that at one induction where the mama was there from 0 cm. That's a lot of time to give fluids.

Because I am seeing epidurals with transfers, it's often because of malposition and the total relaxation of the epidural is a treatment for the malposition. If the muscles were hold the baby in a great position, the baby would have come out at home.

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